Harm and physical effects of circumcision

In this paper Dr John Warren shows how the harm of circumcision arises from the operation itself, when all goes well and as planned, not merely when there are complications.

Abstract

Male circumcision results in permanent changes in the appearance and functions of the penis. These include artificial exposure of the glans, resulting in its keratinization and altered appearance. Additionally, circumcision results in loss of 30–50% of the penile skin, loss of at least 10,000–20,000 specialized erotogenic nerve endings, loss of reciprocal stimulation of foreskin and glans, and loss of the natural coital gliding mechanism, etc. From the point of view of sensation and function, the most important effect is caused by the tissue loss itself. The most sensitive part of the penis is removed, and the normal mechanisms of intercourse and erogenous stimulation are disturbed.

Keywords: Male circumcision, Harm, Complications, Penile anatomy and physiology, Prepuce, Gliding mechanism

Introduction

The physical effects of male circumcision can be considered under the following headings:

Cosmetic effects Glans externalized and keratinized Penile skin and mucosal loss of 33–50% Loss of sensory nerve endings Loss of reciprocal stimulation of foreskin and glans Loss of the gliding mechanism

1. Cosmetic Effects

Circumcision results in an altered appearance of the penis, which, to all intents and purposes, is permanent. While foreskin restoration may be carried out, it is not straightforward and the results are not perfect. It is comparatively easy for an intact man to be circumcised. Some men are perfectly content to grow up with a circumcised penis, while others can be very disturbed by it. Among circumcised men who have contacted NORM-UK for help, the appearance of their penis is often one of their main complaints. They frequently report avoidance of allowing others, particularly other men, to see them naked, and some, therefore, avoid sports.

Penis size

This is a subject about which men have strong emotions. The effect of circumcision reduces flaccid penile length and width slightly, as the normal foreskin often overhangs the glans in the non-erect state. Width is reduced because of the loss of the double layer of skin covering the glans. The erect penis may also be somewhat shortened, as there may be insufficient penile skin to permit full erection. An Australian survey showed circumcised men, on average, to have erect penises 8 mm shorter than intact men (Talarico and Jasaitis, 1973; Richters et al., 1995).

Skin colour

In intact European males, the glans ranges in color from pink to dark purple, while in dark skinned men it ranges from pink to dark brown. Infant circumcision, carried out when the glans is adherent to the foreskin, results in scarring, pitting, and discoloration of the surface of the glans and, over the years, increasing keratinization is likely to lead to further loss of natural color (Fleiss, 1997).

2. Glans Externalized and Keratinized

The normal glans is an internal structure, only exposed briefly during urination, washing, and sexual arousal. Its surface is moist, and is not keratinized. However, circumcision converts the glans into an external organ. Immediately after the operation, it retains its exquisite sensitivity, and contact with clothing causes considerable discomfort, but it soon becomes desensitized, probably as a result of the laying down of a layer of keratin on the epithelium. A few circumcised men report persistent discomfort from contact with clothing throughout their lives. The epithelium takes on the character of skin rather than mucous membrane.

Not only is the appearance of the glans altered, but also there is a dramatic loss of sensitivity. Sorrells et al. (2007) mapped fine-touch pressure thresholds in the adult penis in circumcised and uncircumcised men, comparing the two populations. With regard to the sensitivity of the glans, they showed that the glans in the circumcised male is less sensitive to fine-touch pressure than that of the uncircumcised (intact) male. Bleustein et al. (2005) tested vibration, pressure, spatial perception, and temperature on the glans in the dorsal midline in circumcised and non-circumcised men, and failed to show any significant difference in sensation on the glans between the two groups after correcting for age, hypertension, and diabetes. What is clear is that the glans is the least sensitive region of the penis, in any case, and is only supplied with simple nerve endings, which sense deep pressure and pain (Sorrells et al., 2007; Bleustein et al., 2005; Halata and Munger, 1986).

3. Tissue Loss from Circumcision

It is the tissue loss that causes the most important functional effects of circumcision. What is lost? Thirty to fifty percent of the penile skin, the area in an adult being about 15 square inches (96 cm2), comprising nearly all of the inner and outer foreskin, is removed. The frenulum is sometimes (and in USA-style “high and tight” operations, nearly always) removed. The inner foreskin includes the ridged band, a zone of specialized mucosa encircling the distal end of the inner foreskin, first described by Taylor and colleagues (1996). They described the ridged band in this way:

When retracted, the inner surface of the prepuce displays two zones, ‘ridged’ and ‘smooth’. The first, a transversely-ridged band of mucosa 10–15 mm wide, lies against the true skin edge, forming the outer surface of the tip of the prepuce. In the dorsal midline, the ‘ridged band’ lies above the level of the adjacent ‘smooth’ mucosa and merges smoothly, on either side, with the frenulum of the prepuce. When magnified, the ridged mucosa has a pebbled or coral-like appearance. Unretracted, the adult ‘ridged band’ usually lies flat against the glans; retracted, the ‘ridged band’ is everted on the shaft of the penis. The remainder of the preputial lining between the ‘ridged band’ and the glans is smooth and lax. There is considerable variation in the degree of ridging: older subjects showed less and younger subjects more marked ridging. Some ridging was seen in all the prepuces examined.

Taylor and colleagues further noted that the ridged band is intensely vascularized, which is typical of components of the nervous system. The tightly pleated concentric bands of the ridged band have been likened to the elastic bands at the top of a sock. These expandable pleats arise from the frenulum and encircle the inner lining of the foreskin. They allow the lips of the foreskin to open and roll back, exposing the glans. The ridged mucosa also gives the foreskin its characteristic taper (Fleiss and Hodges, 2002: 7).

The importance of the ridged band lies in its innervation. When he described it, Taylor, a pathologist working on histology, reported that it showed focal, spiky, or more rounded and flatter ridges interspersed with sulci. Meissner’s corpuscles were more plentiful in some subjects than others but, perhaps significantly, they were only seen in the crests of the ridges, occasionally in small clumps that expanded the tips of corial papillae. End-organs were not seen in sulci between ridges. Special stains for nerve tissue showed the additional end-organs and myelinated nerve fibers in the ridges. In contrast, histological examination of the smooth zone of the mucosa showed no ridging and few Meissner’s corpuscles. Meissner’s corpuscles are mechanoreceptors for detection of light touch. They are distributed throughout the skin, but concentrated in areas that are particularly sensitive, such as the fingertips, palms and soles, lips, tongue, face, and genitals. It has been calculated that circumcision results in the loss of at least 10,000–20,000 specialized erotogenic nerve endings (Winkelmann, 1959, 1956).

Also lost in circumcision is about half the smooth muscle sheath that invests the penis, which is known as the dartos fascia and is temperature sensitive. The frenulum, a highly erogenous V-shaped structure that tethers the underside of the glans to the shaft, is frequently destroyed or damaged during circumcision. Circumcision removes several feet of blood vessels, including the frenular artery. This loss of the rich vascularity interrupts the normal flow to the shaft and glans, damaging the natural blood flow of the penis (Netter, 1997: plates 238, 239).

The mucosal surface of the foreskin produces plasma cells, part of the body’s defense system. They secrete antibodies and antibacterial and antiviral proteins, including lysozyme. The list of structures lost includes lymphatic vessels, apocrine glands (producing pheromones, scent signals), sebaceous glands, and Langerhans cells (another part of the defense system).

4. Loss of Sensory Nerve Endings

As already described, circumcision removes the part of the penis most richly supplied with sensory nerve endings, the ridged band. In general, the inner mucosal foreskin is more sensitive than the outer foreskin, which differs little from the shaft skin. This loss is borne out by the results shown by Sorrells et al. If we look at the figure showing fine-touch pressure thresholds, we notice that the lowest threshold is found at position 3, which is the dorsal preputial orifice rim, while the next lowest thresholds are found at 13 and 14, parts of the frenulum, and 4 and 5, which are the mucocutaneous junction and ridged band, respectively. In the circumcised penis, the lowest threshold is found at position 19, the ventral surface of the circumcision scar.

5. Loss of Reciprocal Stimulation of Foreskin and Glans

The mobile sheath of the intact penis allows the foreskin to glide back and forth over the glans. As it does so, it repeatedly folds and unfolds itself. Inevitably, the tactile nerve endings in the glans and, more especially, in the foreskin are strongly stimulated by this action, whether the result of masturbation, foreplay, or penetrative intercourse. During intercourse, the ridged band is alternately stimulated by the glans, when it is turned inwards, and by the vaginal wall, when it is turned outwards. The smooth muscle in the foreskin ensures that it encloses the glans snugly.

6. Loss of the Gliding Mechanism

Bigelow drew attention to the mechanical function of the foreskin during intercourse (Bigelow, 2002: 17). This function provides more enjoyable intercourse for both partners. During sexual arousal, the vagina secretes lubricant fluid allowing penetration to occur comfortably. Then, during intercourse, the intact penis glides in and out of its own skin sheath with each thrust, reducing friction between the penile skin and the vaginal wall, and allowing the vaginal secretions to remain on its surface, rather than being drawn out as they tend to be by the thrusting of the circumcised penis, which during erection may have no slack skin at all.

Masturbation is similarly affected. An intact man masturbates by manipulating his foreskin back and forth over his glans. In a circumcised man, this is not possible, and often a lubricant is needed to permit comfortable stimulation. Circumcision was originally brought into medical fashion in the nineteenth century because it was thought to prevent or at least discourage masturbation. Masturbation was then considered to be both immoral and dangerous to health, though this has long since been disproved. In fact, circumcision does not prevent masturbation in the least, but it probably makes it less enjoyable, though this is hard to prove.

Conclusion

In considering the physical effects of circumcision, we have seen how there is a permanent and irreversible change in the appearance of the penis and the exposure of the glans, resulting in its keratinization and altered appearance. From the point of view of sensation and function, the most important effect is caused by the tissue loss itself. The most sensitive part of the penis is removed, and the normal mechanisms of intercourse and masturbation are disturbed. At the same time, we have learned about the function of the male foreskin, a subject that has been neglected by medical scientists in the past. We have not considered complications of the operation, but merely what ensues when everything goes according to plan.

References

Bigelow J. (2002) The Joy of Uncircumcising! 2nd ed. Kearney, NE: Morris Publishing.

Bleustein CB et al. (2005) Effects of circumcision on male penile neurologic sensitivity. Urology. 65:773–777.

Fleiss PM. (1997) The case against circumcision. Mothering Mag Nat Fam Living. Winter: 36–45.

Fleiss PM, Hodges FM. (2002) What Your Doctor May Not Tell You About Circumcision. New York, NY: Warner Books.

Halata Z, Munger BL. (1986) The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res. 371:205–230.

Netter FH. (1997) Atlas of Human Anatomy, 2nd ed. (Novartis 1997).

Richters J et al. (1995) Why do condoms break or slip off in use? An exploratory study. Int J STD AIDS. 6(1):11–18.

Sorrells ML et al. (2007) Fine-touch pressure thresholds in the adult penis. BJU Int. 99:864–869.

Talarico RD, Jasaitis JE. (1973) Concealed penis: A complication of neonatal circumcision. J Urol. 110:732–733.

Taylor JR et al. (1996) The prepuce: Specialised mucosa of the penis and its loss to circumcision. Br J Urol. 77:291–295.

Winkelmann RK. (1956) The cutaneous innervation of the human newborn prepuce. J Invest Dermatol. 26:53–67.

Winkelmann RK. (1959) The erogenous zones: Their nerve supply and its significance. Proc Mayo Clin. 34:39–47.

John Warren, Physical effects of circumcision, in George C. Denniston, Frederick M. Hodges and Marilyn Fayre Milos (eds), Genital Autonomy: Protecting Personal Choice (Dordrecht, Heidelberg, London, New York: Springer, 2010; ISBN 978-90-481-9445-2 e-ISBN 978-90-481-9446-9)

Dr Warren is a general practitioner in the United Kingdom, and a founder of Norm-UK.

The book may be purchased from Amazon. Individual chapters may be bought and downloaded from the publishers, SpringerLink.

Further information

Historical quotes on the foreskin and sexual function on this site.

Foreskin anatomy at CIRP

Sexual functions of the foreskin at CIRP

The foreskin and sexuality at Circumstitions