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### BRITISH JOURNAL OF SEXUAL MEDICINE: Pages 6-8,
September/October 1994.

The case against
circumcision

John P Warren and Jim Bigelow argue that the practice of circumcision, still widespread in some countries, has little to commend it, and much to answer for

> SUMMARY: The origin of circumcision as a form of ancient sacrifice is discussed. Recently described information about the structure and function of the prepuce is presented. It is suggested that the prepuce is responsible for much of the erogenous sensation in the penis. The indications for circumcision are considered. Unnecessary circumcisions are still being carried out. The methods and results of foreskin restoration in circumcised men are referred to. It is recommended that circumcision should be avoided whenever possible and that there is a need for further research into the location and function of sensory receptors in the male genitalia and the psychological effects of circumcision.

The origins of circumcision are lost in antiquity. Male circumcision is depicted in Egyptian tombs 5,000 years ago 1, while Gairdner refers to evidence that it has its origins long before this in prehistory up to 15,000 years ago 2. We do not know with certainty why this operation was carried out, but many writers have suggested that it was a sacrificial rite. No doubt human sacrifice was widespread, and it seems likely that substitutes for this practice included the sacrifice of domestic animals and mutilations of the human body, of which circumcision is just one example. Circumcision would usually have been carried out as an initiation ordeal at about the time of puberty, but there was a tendency for the age at which it was performed to shift earlier, so that Jewish ritual circumcision has been carried out on the eighth day of life since biblical times.

Ritual circumcision is particularly popular and widespread geographically. An important aspect of sacrifice is the shedding of blood, and circumcision is a notoriously bloody operation, and even in modern surgical conditions haemorrhage can be a problem. A rate of up to 2% is reported by Denton 3, sometimes requiring blood transfusion. Gellis 4 reported that there were more deaths in the USA from the complications of circumcision than from carcinoma of the penis. One can only guess what the mortality from haemorrhage and infections might be in primitive or ancient communities.

Another aspect of sacrifice is that the object which is forfeited should be valuable. The greater the value of the object sacrificed, the more worthy the sacrifice. This should make us wonder what are the value and function of the prepuce. If it were just a useless flap of skin, it would not be much of a sacrifice, and one might just as well shave off one's beard or cut one's toenails. Evidence will be provided below to indicate that the prepuce plays a major role in ensuring the sensitivity of the penis during sexual acts and that circumcision greatly reduces the possibilities of pleasurable sensations. This makes it an ideal sacrificial object, as the circumcised male is able to function normally in society and to procreate, but suffers permanent impairment of sexual enjoyment and bears a visible, life-long reminder of his sacrifice.

The development, structure and function of the prepuce

Although the penis in general is well described in the medical literature as regards its structure and function, not much attention has been paid to the prepuce. It is generally described as a fold of skin which protects the glans. Its embryological development has been described by Gairdner 2, who also described how its development is incomplete at birth and that separation of the prepuce from the glans takes place at a variable time in childhood, 90% being separated by the age of 3 years. ุster 5 described what happens to the remaining 10% and showed that if these penises were not interfered with, natural separation would follow in all but 1% by the age of 17.

Taylor in a preliminary, unpublished study presented at The Second International Symposium on Circumcision, San Francisco, 1991, looked at autopsy material and surgical specimens. He showed that the amount of skin lost by circumcision in the adult is 5-8 cms. in length. He also looked at the structure of the skin that was lost. The outer layer resembles skin elsewhere on the penile shaft, but the inner layer is very different. In the child and young adult it is tightly folded, but it tends to become flattened in older men. He described a fold which he called the frenar band at the mucocutaneous junction, merging with the frenulum. This band is particularly rich in Meissner nerve endings. He showed that this part had a rich blood supply, which it shared with the corpora cavernosa and glans. The histological appearance resembled mucosa rather than skin as it lacked hair follicles, sweat glands and sebaceous glands. The structure resembled most closely that of the labia minora. However no neurophysiological studies have been carried out on the prepuce and at present there is insufficient knowledge to understand its function fully. But the anatomy suggests that the prepuce plays an important role as a specialised sense organ. [CIRP note: Taylor's findings were later published and are now available.]

It is strange that doctors in Western countries will not permit female circumcision, which involves removal of some or all of the erogenous tissue from the vulva for reasons other than major pathology such as malignancy, but will permit, and in some cases encourage, the removal of the male prepuce, which is identical to the female prepuce in its embryological development, cell structure, and nerve and blood supply 6.

Bigelow 7 reports that the prepuce has four functions. Firstly, it is itself sensitive due to the nerve endings on its inner surface, which become exposed during sexual arousal. Secondly, it protects the glans. The protected glans remains soft, moist and sensitive throughout life, but the exposed glans of the circumcised male becomes increasingly thickened and desensitised. Were this not so it would be impossible for a circumcised man to tolerate the abrasion of clothing on the exposed glans. Thirdly, the mobile sheath of skin on the intact penis allows the prepuce to slide back and forth over the glans during foreplay and intercourse. Ritter calls this action "the pleasure dynamic" 8. Fourthly, it provides slack skin on the shaft of the erect penis allowing it to glide within its own sheath of skin during intercourse. This provides for more enjoyable intercourse for both partners and avoids problems with vaginal dryness.

Reasons for circumcision

Circumcision may be carried out for one of three reasons: 1, religious, 2, social, 3 medical. So far as religious requirements to circumcise go, it is not for doctors to argue with someone who believes that God requires him to amputate his prepuce. All the doctor can do is advise him how to carry out the operation safely and humanely.

Social reasons include, for example, the request to circumcise a child so he will look like his father. In the past many doctors have accepted such requests for circumcision without question, and undoubtedly this is still the case in some places.

Medical indications have varied at different times and in different parts of the world. Doctors' views on circumcision may roughly be divided into three positions: Position 1:- pro-circumcision. Doctors who hold this view believe that the prepuce serves no useful purpose and that it is liable to become diseased and therefore is best removed as a matter of public health and hygiene. They may subscribe to the view that smegma is an important cause of carcinoma of the cervix and penis. Some believe erroneously that circumcision protects against sexually transmitted diseases. They often also recommend that the operation should be carried out as early as possible, when, as some still believe, pain is not experienced as it is in the older child or adult. It has been claimed that routine neonatal circumcision reduces the incidence of urinary tract infections in infancy 9,10,11.

Position 2:- the neutral position. Doctors who subscribe to this view will say that routine neonatal circumcision is not necessary, since most boys will never require circumcision, and to carry it out unnecessarily subjects a child to risk and pain and is a waste of resources. However they will readily recommend circumcision in cases of tightness of the prepuce or difficulty in retracting it over the age of, say, 5 years or if asked to do so by the parents.

Position 3:- the anti-circumcision position. Those who subscribe to this view believe that the prepuce has an important function and should be preserved whenever possible, and that its loss seriously impairs sexual functioning and pleasure.

Where are we now?

In Britain the pro-circumcision view appears to have been popular during the 1930's and 1940's, as it was in other English-speaking countries. The advent of the National Health Service in 1948 and the publication of Gairdner's paper in 1949 2, when at least 20% of boys were circumcised, caused a shift to the neutral position in Britain in the 1950's and 1960's. Neither of these factors appears to have had any effect in the USA where pro-circumcision attitudes have held sway up to the present day, and the current neonatal circumcision rate is estimated at 59%, having been 85% in 1980 8. The Task Force on Circumcision stated that newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks 12.

However, attitudes in Britain do not appear to have shifted beyond the neutral position in spite of ุster's paper in 1968 5. The indications for circumcision were discussed by Gordon and Collin recently 13. They estimate that 1 to 2% of boys need circumcision for medical reasons. Those whose prepuce remains non-retractile at 17 are probably suffering from balanitis xerotica obliterans 14. However the cumulative national circumcision rate in Britain is currently 6.6% 15. It was shown in audits of patients referred for circumcision that there was a great deal of misunderstanding about the meaning of phimosis, which was overdiagnosed by referring doctors 16,17.

Smegma has been blamed as a carcinogenic agent. However, it is produced by every mammalian species, both male and female. If it were carcinogenic this would be a serious mistake by Nature, which would threaten the survival of this successful class of vertebrates. Penile carcinoma is described in Jews, though it is rare, and there is no marked difference in incidence between USA where circumcision is almost universal and Scandinavian countries where it is rarely carried out 7. Likewise, cervical carcinoma is no less common in USA than in non-circumcising countries 7.

There have been a number of reports of the evidence for pain experienced by neonates undergoing circumcision 18,19,20.

Reasons for not circumcising

Until recently the structure and function of the prepuce have not been known. Now its important function as a major source of erogenous sensation on the penis has been recognised. Not only is the circumcised man deprived of this sensation, but also his glans becomes thickened and insensitive. The reader may be puzzled why this was not known before. Males are nearly always circumcised in childhood, and so they pass through all their sexually active years with a circumcised penis and therefore have no concept of what normal feeling is. Furthermore, men do not generally discuss their erotic experiences in great detail with one another, assuming that all share the same experiences.

In North America many circumcised men are now becoming aware of their mutilation and the harm that this has done them, and some are starting to seek methods of replacing the lost prepuce. This can be achieved surgically, and a number of operations are described in the literature 21,22,. Foreskin restoration can also be achieved by nonsurgical tissue expansion techniques, described by Bigelow 7. Men who have restored their prepuce describe remarkable improvement in the erogenous sensitivity of the glans and satisfactory restoration of the interaction between the prepuce and the glans, together with a discovery of the gliding action of slack skin on the shaft, which they will not have known before. Even though the unique structure of the inner lining of the prepuce can never be recreated, such men report satisfaction with the results of foreskin restoration.

In view of this knowledge, it is time the medical profession reviewed the indications for circumcision. There is no excuse for amputating normal prepuces that are merely slow to separate. Where genuine phimosis has occurred, consideration should be given to conservative surgery, such as preputioplasty. Doctors should consider carefully before demanding the sacrifice of the most sensitive part of the penis, particularly when, as is often the case, the patient is a child not old enough to understand what is being done.

Conclusion

There is a need for further research into the location of erogenous sensation in the male genitalia, the structure and function of the prepuce and the psychological effects of circumcision, which have not yet been fully evaluated. In the mean time, surgeons should be encouraged to preserve as much penile tissue as possible.

References

1. Blandy JP. Circumcision. Hosp Med 1968; 3: 551-3.
2. Gairdner D. The Fate of the Foreskin. BMJ 1949; 2: 1433-7.
3. Denton J, Schreiner RL, Pearson J. Circumcision Complication. Clin Pediatr (Phila) 1978; 17: 285-6.
4. Gellis SS. Circumcision. Am J Dis Child 1978; 132: 1168-9.
5. ุster J. Further Fate of the Foreskin. Arch Dis Child 1968; 43: 200-3.
6. Wallerstein E. Circumcision: an American Health Fallacy. New York. Springer Publishing Company, 1980.
7. Bigelow J. The Joy of Uncircumcising! Restore Your Birthright and Maximize Your Sexual Pleasure. Aptos CA: Hourglass Book Publishing, 1992.
8. Ritter TJ. Say No to Circumcision! Aptos CA: Hourglass Book Publishing, 1992.
9. Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985; 75: 901-3.
10. Wiswell TE and Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1986; 78: 96-9.
11. Wiswell TE and Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989; 83: 1011-5.
12. American Academy of Pediatrics Task Force on circumcision. Report of the Task Force on circumcision. Pediatrics 1989; 84: 388-91.
13. Gordon A, Collin J. Save the Normal Foreskin. BMJ 1993; 306: 1-2.
14. Rickwood AMK, Hemalatha V, Batcup G, Spitz L. Phimosis in boys. Br J Urol 1980; 52: 147-50.
15. Rickwood AMK and Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989; 71: 275-7.
16. Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R Soc Med 1992; 85: 324-5.
17. Williams N, Chell J, Kapila L. Why are children referred for circumcision? BMJ 1993; 306: 28.
18. Stang H, Gunnar MR, Snellman L, Condon LM, Kestenbaum R. Local anesthesia for neonatal circumcision. JAMA 1988; 259: 1507-11.
19. Grimes DA. Routine circumcision of the newborn infant: a reappraisal. Am J Obstet Gynecol 1978; 130: 125-9.
20. Kirya C and Werthmann MW. Neonatal circumcision and penile nerve block-- a painless procedure. J Pediatr 1978; 92: 998-1000.
21. Goodwin WE. A technique for plastic reconstruction of a prepuce after circumcision. J Urol 1990; 144: 1203-5.
22. Lynch MJ and Pryor JP. Uncircumcision: a One-stage Procedure. Br J Urol 1993; 72: 257-8.

J P WARREN, FRCP
Physician, Princess Alexandra Hospital, Harlow. CM20 1QX.

J BIGELOW, PhD
Psychologist, POB 52138, Pacific Grove, CA 93950

Citation:

- Warren J, Bigelow J. The case against circumcision. Br J Sex Med 1994; Sept/Oct: 6-8.

(File revised 2 September 2002)

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