Every part of the human body has a function and a purpose. Millions of years of evolution have fashioned the human body into a model of refinement, efficiency, and elegance.
The foreskin is an integral and essential part of the penis. Every reason ever offered to justify the infliction of prophylactic surgical amputation of the foreskin has been proven false. As a result, the rate of neonatal circumcision has dramatically fallen from over 90% in the 1970s to the present rate of 35.5% in the Western United States. Unfortunately, the rate still remains high in the Midwest and South. The legacy of the mass circumcision campaigns of the recent past, however, has resulted in widespread ignorance about the foreskin and the anatomy and functions of the penis. Ignorance and error is rampant in American medical practice and education. Most American produced textbooks present the human penis without explanation as being circumcised! This would be analogous to African medical textbooks presenting female reproductive anatomy minus the labia minora, labia majora, and clitoris.
The foreskin, like all other body parts has a unique function and a complex anatomical structure. Since an increasing number of American male newborns are now allowed to remain genitally intact, as their European counterparts have always been, physicians should acquaint themselves with the basic anatomy and functions of the foreskin in order to better care for and protect the interests of their patients.
Anatomy of the Foreskin
The foreskin is an integral part of the penis. Depending on the length of the penile shaft, the foreskin represents from 60% to 80% of the penile skin covering. The foreskin also represents 25% to 50% of the overall length of the flaccid penis.
At birth and throughout childhood the foreskin is fused to the glans. This desirable situation protects the preputial space and meatus from contaminants. By puberty, the glans and foreskin will have separated and developed independent mucosal surfaces.
The foreskin is a complex and unique structure. It is analogous to the eyelids or lips. AB a modified extension of the penile shaft skin, the foreskin covers the glans penis and extends beyond it before folding in upon itself and finding its circumferential point of attachment just behind the corona glandis. The skin of the foreskin is lined by the peripenic muscle sheet, a muscle layer with logitudinal fibers. At the preputial orifice, the muscle fibers are arranged in a whorled manner and form a sphincter.
On the underside of the glans, the point of attachment is advanced towards the meatus and forms the frenulum, which is analogous in form and structure to the labial and glottal frena. The frenulum holds the foreskin in place, and in conjunction with the smooth muscle fibers of the foreskin automatically returns the everted foreskin to its forward position. The frenulum rises from its point of attachment behind the meatus and encircles the inner foreskin forming the frenar band.
The internal surface of the foreskin is divided into two distinct zones: the soft mucosa and the frenar band. The soft mucosa lies against the glans penis and contains ectopic sebaceous glands which continuously excrete a natural sebaceous emollient and lubricant, commonly referred to as smegma. The frenar band is continuous with the frenulum and consists of tightly pleated bands which encircle the tubular distal portion of the inner foreskin just in front of the urinary meatus.
Functions of theForeskin Protection
Analogous to the eyelid, the foreskin protects and preserves the sensitivity of the glans by maintaining optimal levels of moisture, warmth, pH balance, and cleanliness. The glans itself contains no sebaceous glands and relies on the sebaceous glands in the foreskin for production and distribution of sebum to maintain proper epithelial lubrication.
Viral and Bacteriological Defense
Glands in the soft mucosa produce antiviral and antibacterial secretions
such as lysozyme. The urinary meatus is an entry point into the body.
From infancy to adulthood, the sphincter at the preputial orifice
insures optimum protection of the glans and urinary meatus from contaminants
of all kinds.
Preputial Erogenous Sensitivity
The foreskin possesses a richer variety and greater number of specialized
nerve receptors than any other part of the penis. The glans is stimulated
by the mechanical rolling pressure of the foreskin and not by friction.
The frenulum, the frenar band, and the preputial orifice contain dense
concentrations of specialized erotogenic nerve receptors, such as
Meissner corpuscles, Merkel Discs, and Genital End-Bulbs. These nerve-rich
structures constitute the primary orgasmic triggers. They are stimulated
by stretching the foreskin and by the movement of the glans within
The natural sexual functions and mechanics of the penis depend entirely
upon the foreskin. The function of the foreskin in coitus is to permit
intercourse to take place under optimal conditions without friction
between the mucosal surfaces of the two participants. The penile shaft
slides within its own skin which is held in place by the vaginal muscles.
Nature has designed it so that the female partner is stimulated by
pressure and not by friction. The natural penis is self lubricating.
Vaginal secretions serve only to ease the initial insertion of the
penis. Preputial secretions enable the foreskin to evert and revert
smoothly over the glans.
Care of the Foreskin
The natural penis requires no special hygienic care. The internal
structures of the penis, like the vagina, are self cleansing. In infancy
and childhood the penis should never be tampered with by parents,
physicians, or other care givers. The child's foreskin should never
be retracted. Smegma is not dirt. It is beneficial and necessary.
It should not be washed away in childhood. The adult male may gently
rinse the exposed glans with warm water according to his own self-determined
needs. At any age, soaps of any kind should be avoided as these will
dry out the preputial mucosa. Dermatological infections of the foreskin
such as balanoposthitis are commonly caused by forced retraction and
soap. The retrospective studies alleging a 1.26 percentage point increased
rate of urinary tract infections among intact boys have been largely
invalidated because of selection bias and a 16% rate of false-positive
diagnosis. It has been proven that retraction and washing of the infant
foreskin can cause urinary tract infections by irritating the mucous
membranes and destroying the naturally occurring beneficial bacterial
flora which protects against pathogens.
Harm of Circumcision
Circumcision is a more serious amputation than generally thought.
It destroys all the natural mechanical functions of the penis, leaving
it only with the ability to become erect. Circumcision necessarily
involves a preputial neurotomy, a frenar neurotomy, a posthectomy,
a frenectomy, a subtotal penile shaft skin removal, and a penile endocrinectomy.
Circumcision amputates three feet of veins, arteries, and capillaries;
several feet of nerves; the preputial muscles; and 60% to 80% of the
penile skin system.
Harm to Female Sexual Partners
Without the mobile sheath of the foreskin, the circumcised penis
acts like a ramrod in the vagina. This is unnatural and has negative
health consequences for women. Trauma such a vaginal abrasion, dryness,
pain and coital bleeding are unique to the female partners of circumcised
men. Female partners of intact men do not suffer from these problems.
Female partners of circumcised men must resort to artificial sexual
lubricants to replace the natural lubricants lost by circumcision.
No studies have ever been undertaken to determine the potential harm
of prolonged internal exposure to these artificial chemicals
Harm During Masturbation
Without the mobile sheath of the self-lubricated foreskin, and without
the normal orgasmic triggers in the foreskin, circumcised males are
obliged to invent unnatural ways to stimulate the remaining portions
of their penis. Circumcised men often must resort to using artificial
chemical lubricants and must apply physiologically dysfunctional manual
friction to the glans. Nature did not intend sexual stimulation to
be so difficult. The health consequences of prolonged exposure and
absorption of these artificial lubricants has never been studied.
Harm to the Brain
The unalleviable and severe pain of the surgery has long-lasting
and irreversible detrimental effects upon the developing brain. The
surgery adversely alters the pain perception centers of the brain.
Developmental neuropsychologist James Prescott, writes:
It is not without psychobiological consequences that the brain system
which is designed for the experience of pleasure and the expression
of sexual love is first encoded with extraordinary and excruciating
pain. In such individuals, all subsequent acts or experiences of genital
pleasure are experienced upon a background of genital pain that is
now deeply buried in the subconscious/unconscious brain... The brain
system that has been designed for pleasure has first and foremost
become saturated or encoded with pain that now limits and qualifies
all subsequent experiences of pleasure. When these early experiences
of genital pain are followed by a developmental deprivation of physical
affectional pleasure in the maternal-infant relationship and in the
adolescent sexual relationship, then violent destructive behaviors
are the inevitable outcome.
Dr. Prescott indicates that the levels of violent crime (especially
violent sexual crimes such as rape) have increased in direct proportion
to the increase in the number of sexually active circumcised males
in American society.
Circumcision severs all the nerves to the prepuce and frenulum. This
results in sensory deprivation to the brain. Sensory deprivation causes
permanent brain damage and/or dysfunction. Brain atrophy and/or dysfunction
due to sensory deprivation is well-documented by Nobel Prize winners
D. H. Hubel and T. N. Wiesel. The brain receptors that represent the
sex nerves atrophy or become dysfunctional from disuse.
Harm to Hygiene
The intact penis in childhood requires no care. The newly circumcised
penis, on the other hand, is left with a large circular amputation
wound which demands constant attention to avoid infections that can
be serious or even fatal. Infections that lead to death are generally
caused by tuberculosis, meningitis bacilli, systemic blood poisoning,
or gangrene. These organisms enter the amputation wound because it
provides easy entry, not because the child is predisposed to infection.
The amputation wound from circumcision is larger than is generally
imagined. The wound is not merely the circular point of union between
the outer and inner layers of the foreskin. The entire glans is also
an open, raw wound. At birth and through childhood, the glans has
no skin of its own. The foreskin adheres to it like the fingernail
to the finger. To perform circumcision, the foreskin must first be
torn from the glans, in effect skinning the glans alive. The result
is a large area of raw bloody, flesh, covered at best with an undeveloped
proto-mucosal layer. A similar type of surface exists under the fingernails.
Pathogens can easily enter the bloodstream and tissues through the
raw glans and even more easily through the open wound of the foreskin
stump. Even after the wound has healed, the glans and meatus are now
forced into constant unnatural contact with feces, urine, amoniacal,
chemically treated diapers and other environmental contaminants.
Harm to the Immune System
The mucous membranes which line all body orifices are the first line
of immunological defense. The glands in the foreskin which secrete
antiviral and antibacterial chemicals are destroyed. The destruction
of the mucous membranes of the penis weakens the body's immune response.
Rigorously controlled studies demonstrate that circumcised men are
more at risk for gonorrhea, human papilloma virus (HPV), and herpes
simplex virus type 2. Otherwise, studies show no difference in the
rates of all other common STDs between men whose penises have been
circumcised and those whose penises are still as Nature so wisely
designed them. The authors of these studies conclude that the presence
of the foreskin may confer protection to the penis from STD infection.
Recent studies have disproved the myth that the foreskin causes penile
cancer. Maden and associates reported penile cancer among 20% of elderly
neonatally circumcised patients from rural areas, born at a time when
the neonatal circumcision rate was approximately 20% for rural populations.
This study also demonstrates that the rate of penile cancer among
neonatally circumcised males has risen in the US relative to the rise
in the rate of neonatal circumcision. Frisch and associates found
a rapidly falling rate of penile cancer, presently measured at 0.82
per 100,000 in Denmark (a circumcision free nation). The U.S. has
a higher rate of 1 per 100,000. On the basis of this evidence, one
could conjecture that the foreskin confers protection against penile
The histological changes that occur to the remaining portions of
the penis after circumcision may be responsible for a weakened immune
response to bacterial and viral invasion. After circumcision, the
mucous membrane of the glans and remaining preputial stump (if present)
dry up, toughen and keratinize, taking on an unhealthy, sclerotic
appearance. Sclerotic, keratinized tissue is the least resistant to
infection and trauma. The cracks and lesions that occur in non-elastic
sclerotic tissue provide an easy point of entry for microbial invasion.
It is important to note that the United States has both the greatest
number of circumcised sexually active adults in the Western world
and the highest rate of sexually transmitted diseases, including HIV/MDS.
Harm to the Body
Circumcision surgery has a complication rate of 1 in 500 and a reported death
rate of 1 in 500,000. The potential for surgical complications to
be tragic and irreparable is high. The infliction of such a high surgical
risk for nontherapeutic reasons is unethical since the individual
who must live with the consequences of this non-therapeutic amputative
surgery has not consented to its performance.
Violation of Human Rights
Before introducing the policy of routine circumcision of newborn
males after World War II, circumcisers did not examine the human rights
violation involved in the policy of forcing or even allowing unconsenting
individuals to undergo surgery to amputate healthy penile tissue.
More than just physical harm, circumcision causes political harm.
Even if circumcision were physically harmless, which it is not, it
would still constitute a human rights violation. Furthermore, circumcisers
have never shown that the stated public health goals could not have
been achieved by a less coercive policy than by foreskin amputation.
The failure of the policy of mass circumcision to achieve the public
health goals of reducing the rates of STDs, cancer, and genital infections
is made more tragic in light of the harm, sexual dysfunction, morbidity,
and risk of fatality unjustly inflicted on the past few generations
of American males.
Every male has a right to keep his birthright of an intact penis.
Children have a right to expect their parents or guardians to protect
this right while they are developmentally unable to protect it themselves.
Parents and physicians have no right to remove healthy body parts
from nonconsenting individuals. In 1995, the American Academy of Pediatrics
Committee on Biothics agreed. According to their recent statement,
only a competent patient can give patient consent or informed consent.
An infant is developmentally incompetent to consent to non-therapeutic
surgery. The concept of informed parental permission does not apply
to circumcision, since the concept of informed parental permission
allows only for medical interventions in situations of clear and immediate
medical necessity, i.e., diseases, trauma, or deformity; the natural
human penis satisfies none of these conditions.
Furthermore, since it is the infant and not the parent who must live
the rest of his life with the consequences of this treatment, the
individual's legal right to refuse treatment as well as the right
to seek alternative treatment has been violated. Likewise, the basic
human right to autonomy, self-determination, and the right to an intact
body as outlined in Article 5.1 of the American Convention on Human
Rights (1969) and Article 1.1 of the International Convention on Human,
Civil and Political Rights (1966) are violated by the performance
of nontherapeutic circumcision.
The physician today has a duty to refuse to perform circumcision.
He also has a duty to educate parents who request this surgery for
their children. Modern parents who have come of age in the era of
mass circumcision may require gentle counseling in this area. Frequently,
circumcised fathers today demand that their children be circumcised
in order to 'match' them. There could not be a worse reason to subject
a child to surgery than this. A simple refusal of this irrational
demand discourage circumcision and to refuse to perform it.
Physicians today have a unique historic opportunity to correct the
mistakes of the past by realigning medical practice with ethics and
the principles of human rights. Every individual has a right to the
body he or she was born with. Physicians have a duty to protect this
right and to uphold the first tenet of the Hippocratic oath "First,
Do No Harm."
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