What exactly is circumcision and what is it not?

Francisco Garcia

Infant circumcision is made more acceptable by believing the notion that there is a flap of skin at the end of the penis called the foreskin which hangs over the glans and circumcision simply removes that flap. This is factually incorrect. By thinking that the foreskin is separate or extra tissue it is easier to believe that its removal does little to impact or change the rest of the skin of the penis.

There is really no separate anatomical structure called the foreskin. Rather there is one single continuous skin sheath of the penis which is called the skin system. This single, uninterrupted skin sheath may, at any given time, fold to varying degrees over the glans or retract to reveal it. The amount of the skin system that is folded over can be referred to as the forefold of the skin system. Its extent changes often to accommodate degrees of erection, and it is never a separate structure from the skin of the shaft.

What the operation called circumcision actually does then is to interrupt and significantly reduce the skin system of the penis to a fraction of its normal anatomical and functional extent.

The skin system of the penis

The intact penis is covered by one single continuous skin sheath or skin system. The skin sheath is partly folded at different times. This folded part of the skin system is called the foreskin or prepuce.

The fold of skin is often mistaken as a single layer, or a flap of skin. This is wrong. Instead, it is a free, two-layer fold that forms when the skin coming down the penis from the shaft folds underneath itself somewhere near the tip of the penis then travels back to an attachment point behind the glans (see figures 6 and 4). The two sides of the fold do not adhere to each other even though they lie flat against each other appearing to form a single flap of skin.

Also, in the adult the skin system does not adhere to the glans so it can unfold back off of the glans, leaving it fully exposed. When we speak of this skin sheath we are not talking about the surface of the glans itself in the same way that we talk about the surface of the shaft, because the glans has no real skin. When we talk about the skin covering of the glans, this can only mean the foreskin. The foreskin is its skin covering.

The fictitious foreskin

A significant anatomical error has been made historically and continues today in describing the penis by delineating the foreskin as a separate anatomical structure from the shaft skin. People talk about the foreskin separately from the shaft skin. This is a mistake. It is not correct.

The foreskin is not a separate anatomical structure from the rest of the skin of the penis. This is actually an artificial separation. When the word foreskin is used, rather than referring to a separate part of the penis, it means the part of the continuous skin system which happens to be folded over the glans at any given time. So there is no real anatomical border to the foreskin. Since the proportion of the skin system that is folded over the glans increases and decreases by folding and unfolding to various degrees all the time, we realize that foreskin is a poor way of describing the anatomy of the penis. Instead, more accurate terminology might be to describe that part of the skin system which covers the glans as the forefold of the skin system.

Unlike the false border between foreskin and shaft skin, there is a real anatomical border which exists in the skin system. It is between the mucosal, or non-keratinized, part of the skin system (which consists of the inner lining of the foreskin along with the surface of the glans) and the keratinized part (which is the outer penile skin, including the outer foreskin). That border is at the most distal part, or tip, of the skin system - it is the tip of the forefold (see figures 6 and 7).

The mobility of the skin system

The entire skin system moves freely. In the intact (uncircumcised) male, the penis has a low friction gliding plane immediately beneath the surface of the skin which is like no other body structure. This means that the skin of the penis does not adhere to the underlying tissue the way that skin adheres to other parts of the body. This unique quality allows the entire skin of the penis to move as a unit back and forth longitudinally or around the shaft circumferentially making it the most mobile skin in the intact male.

The skin system covers the head of the penis to varying degrees depending on moment-to-moment factors such as the state of erection and temperature. The free fold of the skin system which we call foreskin unfolds and re-folds constantly to varying degrees, adjusting to the current state of the penis. It is a very dynamic system. The foreskin, among other functions, provides the penis with a reservoir of skin which is needed during erection. The skin of the erect, intact penis is still mobile and loose, allowing the mucosal inner foreskin to roll back and forth over the glans (see figure 7).

Thus, the dividing line between what we call the skin of the shaft and foreskin is regularly crossed by the shaft skin or foreskin. The delineated foreskin may become entirely shaft skin when the penis becomes more erect because it is now around the shaft. And if the penis shrinks momentarily beyond its usual flaccid state, perhaps due to a cold swim at the beach, some of the shaft skin is now foreskin because it covers the glans. The skin system is a dynamic, mobile and flexible skin sheath that moves and adjusts to the momentary needs of the penis (see figure 7). Such a system is not normally observed in the circumcised male.

Another anatomical error is committed in describing the foreskin as a flap of skin protruding from the shaft skin (figure 6a). This notion presumes that the foreskin is a single layer of skin, like the skin of the shaft, which grows from the shaft to cover the glans. In describing the foreskin this way it is easier to see it as redundant or extra skin and it is more difficult to see how removing it might impact the rest of the penis. This description of the foreskin is inaccurate. The foreskin is not extra skin which protrudes from the shaft. There is no extra skin on the body - this is a silly notion. Instead, it is a free, double-layered fold - an integral part of the skin system. The foreskin extends from a point on the shaft behind the glans to cover the glans then folds back underneath itself to the same attachment point on the shaft, usually near the glans (see figure 6). The eyelid works much the same way. The eye lid is not a single flap of skin, but rather two freely moving layers of a fold of skin, so that both the foreskin and the eyelid have two layers. That's why it is more appropriate to refer to the foreskin as the forefold of the skin system.

In reality then, infant circumcision does not remove the tip of the penis or redundant skin nor does it remove a separate structure called the foreskin. Rather, infant circumcision deletes a significant percentage of the skin system of the penis, rendering the skin system relatively dysfunctional and rendering the penis less dynamic.

The triple whammy

The circumcised penis loses sensitivity in three ways:

Loss of the foreskin nerves themselves. As has been demonstrated by studies such as the one by Dr. Taylor and by the testimonials of the majority of intact men, the inner foreskin possesses a greater density of nerve endings. It is thought to be more erogenous than even the glans. The is no question that the foreskin is a highly erogenous tissue. This tremendous amount of sensitivity is lost completely when the forefold of the skin system is amputated. In addition to this, the most sensitive part of the penis, the frenulum of the foreskin, is either partially or totally removed in most infant circumcisions. The frenulum is the continuation of the inner foreskin which attaches to the underside (ventral part) of the glans. Thus, a significant percentage, if not the majority, of erogenous nerve supply to the penis is removed in circumcision at birth.
Damage to the glans. The erogenous sensitivity that remains after circumcision is primarily in the glans. This is further reduced by removal of the protective foreskin which leaves the glans permanently exposed. Unlike the shaft of the penis, and most of the rest of the body, the head of the penis, does not posses its own attached skin. This structure, like the eye ball and the gums of the mouth, is a somewhat naked structure. Its surface is non-keratinized, like that of the gums, the eye ball, and the clitoris in women. That means that it does not posses a protective thick layer like the keratinized skin of the outer penile skin system. Like the gums and the eye ball, the glans of the intact penis has a retractible skin covering. The skin covering of the glans is the foreskin. The eyelid is very similar in architecture to the foreskin. If the eyelid were removed and the eyeball were to become keratinized, you'd have a much harder time seeing. The same is true of the glans. It becomes artificially keratinized (dry, ha rdened, discolored, and wrinkled) as a result of permanent exposure, and thus less sensitive. Because most American men are circumcised and have a glans of this nature, it is harder to notice the abnormality. But just compare the glans of an intact man with that of a circumcised man next to each other and you'll notice a big difference. Thus, in addition to removing lots of erogenous nerve endings in the inner foreskin and frenulum, circumcision further desensitizes the remaining sensitivity of the glans by leaving it exposed.
Loss of skin mobility. The nerve endings in the glans are predominantly complex touch receptors also known as mechanoreceptors. This is different from the light touch receptors of the skin which detect surface friction. The mechanorecptors are best stimulated by massage action rather than surface friction. Thus, the glans is best stimulated to feel pleasure by a rolling massage action. With an ample and highly mobile skin system that rolls over the glans with pressure from the opposing surface, this optimal stimulation of the glans is achieved while avoiding direct friction of the delicate glans surface. Direct friction tends to fire off pain receptors causing irritation and also causes further keratinization of the glans. With the skin system of the penis significantly reduced by circumcision, the mobility is essentially gone and now the penis is a static mass with no dynamic self stimulation mechanism. Now, it must be rubbed. Direct friction is now the primary form of stimulation. So then circumcision further reduces erogenous sensitivity in the penis by reducing skin mobility and thus the ability to use the foreskin to massage the glans. The combination of foreskin and glans in concert results in an even higher level of stimulation which is unknown to the circumcised male.

Conclusion

Circumcision of an infant male significantly reduces erogenous pleasure potential in his penis when he becomes sexually active and continues to be reduced as he ages until, in many cases, he is left with relatively little sensation.

Adult Circumcision vs. Infant Circumcision

A common misperception is that infant circumcision is preferable to adult circumcision because it spares a man pain and trauma. Many physicians however say the opposite and critics admit that most of their objections to infant circumcision cannot be applied to the adult procedure. Here's why:

More precise with better outcome. Circumcision of an adult can be more precise and less risky than for the infant. This is because the adult penis is fully formed. Many plastic surgeons operate on the penis in the erect state because this way it is clear to what extent the skin is stretched during erection. In the infant, this more precise method cannot be employed. Also, based on the knowledge of his own penis, the adult patient can specify how much tissue to remove, the infant cannot. In terms of how much tissue to remove, there is much more guess work involved in the infant and often too much skin is removed. In adult circumcision precise instruments are used. In the infant, usually more cumbersome and less precise instruments like the Gomco clamp are used. The results of operating on a fully formed penis, in the erect state, with precise instruments by a trained surgeon, benefit the adult and not the infant.
Reduced risk of injury. For the same reasons mentioned above, injury to the penis is less likely in adult circumcision than in infant circumcision. It is less likely that too much or too little tissue will be removed and the chances of lacerating the glans itself are also minimized. Scarring is also reduced in the adult.
Reduced loss of sensitivity. Because in the adult, the penis has had many years to develop with a foreskin covering, the glans is fully sensitive at the time of the circumcision. The glans has grown with its protective covering and the foreskin has already separated naturally from the glans. This spares the adult some of the sensitivity loss that occurs when circumcision is performed at birth. At birth, the foreskin must be torn away from the glans to which it is normally adhered. Then, the denuded glans of the infant spends much time exposed to caustic urine while in diapers. In adult circumcision this early damage to the glans is avoided.
Personal choice. With adult circumcision the patient is making a personal choice to have himself circumcised. He has the option of comparing the pros and cons and has had the opportunity to know what having a foreskin is like. This eliminates the lack of choice objection made by critics. With elected adult circumcision, critics see no violation of rights.
Reduced potential psychological effects. With adult circumcision potential psychological effects are reduced. This is because the patient understands the experience. He knows why it is happening and that he has chosen this. Anesthesia is used in the adult and is usually omitted or ineffective in the infant. In contrast, the infant has an experience of inexplicable pain and terror which he cannot rationalize as an adult. Some speculate that this intensely painful experience for the infant can lead to problems later on. Although on the surface it may seem that an infant is less sensitive to or unaware of the circumcision experience, he does experience it fully and because of his very formative and psychologically sensitive age, the experience is thought to be potentially moreimpacting than it is for the adult.

Even though the facts do not support the claim that adult circumcision is worse than infant circumcision, some pro-circumcision advocates contend that adult circumcision is painful, traumatic and dangerous, and that for this reason most adult men who are intact choose to remain uncircumcised. But when intact men are asked about the idea of being circumcised, most say that they have no desire to give up this part of their body - there is no reason to even consider it. Their foreskin gives them no more trouble than their eyelids, lips or testicles. Instead it affords them pleasure and comfort. Anti-circumcision advocates say that it is ridiculous to presume that the idea would even cross an uncircumcised man's mind. To them, it is the same as asking why intact women don't think about having the clitoral foreskinremoved.

December 11, 1995

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