|The Foreskin is Necessary
by Paul M. Fleiss, MD, MPH and Frederick Hodges
|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 foreskin.
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 cancer.
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.
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.”