FUNCTIONS OF THE FORESKIN

George C. Denniston, M.D., M.P.H.

Presented at The Second International Symposium on Circumcision, San Francisco, California, April 30-May 3, 1991.


Abstract:

Beginning with the development of the embryo, the structure of human genitalia is described. The male foreskin has three important physiological functions that circumcision irreversibly destroys. The Gomco clamp and Plastibell circumcision devices and procedures are compared, and religious circumcision procedures are explained. Examination of the risks and alleged benefits of newborn circumcision will include a discussion of immediate and long-term complications, indications and contraindications, and alternative procedures. The question is raised: Do physicians who circumcise babies honor the first maxim of medical practice, "Primum non nocere" (First, do no harm)?

 

False claims

       The history of circumcision in the United States is filled with excuses for doing circumcisions. First it was alleged that circumcision prevented masturbation, and that masturbation caused insanity. We now know that this idea is incorrect.

       More recently, it was claimed that circumcision reduces the risk of cancer of the female cervix. That has now been scientifically refuted, but not before millions of young American boys had their foreskins amputated.

       Now some doctors are still talking about circumcision preventing cancer of the penis. Even if it did, who in their right mind can justify circumcising 100,000 male infants to possibly prevent 1 cancer of the penis in an older man? Given the risk of death from circumcision, several infants would die to help prevent this one cancer. It would be more effective to remove all infant female breasts. That would prevent much more cancer.

       Urinary tract infections are another excuse. Even if circumcision did prevent urinary tract infection, we would have to do 100 circumcisions to possibly prevent 1 treatable urinary tract infection.

Circumcision neurosis

       The continuing tragedy is that men who have been circumcised do not act rationally. Many of them are unable to see that there is anything wrong with circumcision, and continue to carry out this unnecessary surgery on others without their consent. These doctors continue to violate the first and most important maxim of medical practice, PRIMUM NO NOCERE, First, do no harm.

Medical Ignorance

       Few doctors really understand what they are doing when they amputate the foreskin, for they have never studied how the penis develops before birth.1

Foreskin growth and Development

       The penis begins its development as a microscopic protuberance in the male fetus 6 weeks after conception. As it grows outward, a thick layer of epithelial cells, which will become skin, piles up at the base in folds during the next two weeks. At this stage, the tube within the shaft, the urethra, has developed only part of the way down the shaft.

       Then, at the 10 week horizon, the glans, seen head on, begins to develop two downward growing folds of tissue, like the twin hulls of a catamaran. By the 15th week these fold have fused at the bottom creating a tube within the glans. Now the urethra is extended to the tip. If this step fails to take place, a condition known as hypospadias, where the urethra opens short of the tip, will be present at birth.

       With further growth of the shaft and of the glans penis, the skin comes forward to completely cover it by the 15th week.

       >From the 15th week on, the skin covers the glans completely, with a small opening at the tip. A distinct layer of cells attaches the skin most firmly to the entire surface of the glans. This skin is the skin of the glans penis. It has not yet separated to create two distinct organs, the glans and the foreskin.

       Beginning around the 15th week and continuing gradually for as long as 17 years, a process begins which ultimately separated the foreskin from the glans. This fascinating process begins with the flattening of some cells in the area between the glans and the foreskin. These flattened cells round up into a ball, containing many layers of cells. The central cells are necessarily cut off from nutrients, and dies, forming a space filled with the products of dead cells. Many such whorls of cells form in this area between the glans and the foreskin, and create spaces; these spaces coalesce, and eventually create the preputial space, permitting full retraction of the foreskin from the glans.

The Newborn Condition

       At birth, virtually all males have a glans penis covered with skin. In almost all of them (96%), this skin is still attached to the glans like normal skin. Only 4% have a fully retractable foreskin at birth.2

       The implications of this finding are enormous. Any doctor or other person who inserts a probe into this space between the foreskin and the glans thinking that he is breaking adhesions is mistaken. Anyone who attempts to forcibly retract the skin is tearing the skin off an extremely sensitive organ. This person is literally skinning the penis alive. The facts of penis development tell us so.

       It is not until the 3rd year of life that 90% of young boys have fully retractable foreskins, and it is not until 17 years of age before virtually all boys have fully retractable foreskins.3

       The facts of penis development demonstrate to us that an unusual process separates the foreskin from the glans in its own good time, covering the infant glans tightly to protect it from fecal contamination; covering the glans to protect it when, while its owner is a child, it is not required for procreation; and finally, freeing up the cover when it is needed for reproduction. There is no reason to interfere with this natural process.

       What is another important function of the foreskin? To answer that, it is first necessary to look at the function of another organ, namely the penis. The penis has two obvious main functions. It is used for urination and for procreation. But the penis is not required for urination. Witness the female of the species. She does not have a penis, and yet she is perfectly capable of urination. The penis may be a convenient organ for urination, but it is certainly not required.

Functions of the Foreskin

       We can then say that the major function of the penis is procreation, that is, the perpetuation of the species. Without the penis, there would be no more humans.

       The penis cannot procreate in the relaxed or flaccid state. It must erect, engorging with blood, to perform its major function. With this change in condition, from being relaxed to being erect, comes an increase in length of approximately 50%. Now where does this enlarged erect penis obtain skin to cover its significantly elongated shaft? >From the foreskin.

       In the relaxed state, the tip of the penis of the intact adult male is covered by the foreskin, which consists of a fold of skin overlying a complex mucous membrane. As the shaft of the penis elongates with erection, this double layer becomes a single layer which covers the longer shaft.

       In spite of these self-evident functions, some people have tried to argue that the foreskin does not have a function. When I was a medical student, several decades ago, it was thought that the appendix was the one organ without a function. I was taught that the appendix was a vestigial organ, left over from the remote past. We now know that this is not true. The appendix functions as part of the immune system, producing large numbers of lymphocytes. Since the known parts of the body have a function, the probability of the foreskin no having one is virtually nil.

       The foreskin covers the elongated shaft of the penis during erection; at other times it protects the sensitive glans penis. The foreskin contains many minute muscle fibers which give it tone. It covers the glans snugly, and helps to prevent the glans from developing a thick, many layered epidermis, which happens in the absence of the foreskin. This thickened epidermis reduces sexual sensitivity.

       Since the penis is used for procreation only a few times in the entire life of the individual, sexual pleasure must also be a major function, and the foreskin is an integral part of that pleasure. Many anthropologists believe that sexual pleasure with an available mate contributes to the stability of the pair bond. Surely it is not the aim of ethical doctors to interfere in matters of such vital importance.

Male Feelings

       Listen carefully to what men have to say about their own circumcisions. These are direct quotes, compiled by John Erickson and Jeffrey Wood.

      

I think I could have accepted a deformity that was an accident of nature, but I can't accept that someone did this to me.

My feelings about the doctor who circumcised me are too violent to describe.

I have never been able to accept the fact that when I was a baby someone cut part of my penis off. The sheer monstrousness of it haunts every waking moment of my life. Sometimes I'm beginning to make some sort of adjustment to it, but then I see an unmutilated man in a shower or magazine and I become overwhelmed by uncontrollable feelings of outrage and disbelief that I was made the victim for life of something so sick.

There's something very wrong and very frightening about a society that systematically tortures and mutilates babies.

I am Jewish and I hate the tradition that robbed me of my best part.

I was circumcised when I was five, seventy years ago. I felt rage then and I still feel rage now.

The worst thing about circumcision is that it produces circumcisers.

I wish I could circumcise every uncircumcised man in the world, so they'd all be like me. I don't have a foreskin and no one else should have one either.

Butchers!

I was circumcised by force when a child, and it has ruined my entire life as far as I'm concerned.

       Fear, pain, crippling, disfigurement and humiliation are the classic ways to break the human spirit. Circumcision includes them all.

Medical Rationalizations

       Despite the foreskin's important functions, the amputations continue. Doctors who do them try to justify their actions. When they suggest that it will prevent cancer of the penis, there is an alternative. It is generally agreed that the hygiene of men who develop cancer of the penis has been poor. Since the simple act of cleaning beneath the adult foreskin can help prevent cancer of the penis, doctors could simply wait until the man is of age, and let him choose whether he wants his foreskin removed, or whether he would prefer to retract his foreskin whenever he showers!

       Urinary tract infections (UTI) may well be caused by two improper medical procedures, and not by the foreskin. Swedish scientists from the Karolinska Institute in Stockholm claim that such infections are caused by colonizing the newborn infant with foreign bacteria from the hospital nursery. They recommend strict rooming-in to permit colonization of the infant by its own mother which would thus prevent these infections.4

       Second, the colleagues of the author who advocates circumcision to prevent UTI taught the mothers in the study to retract the foreskin, perhaps tearing the skin off the glans, in the mistaken belief that this was proper care. This raw surface may then become a good site for the growth of bacteria which can ascend the urethra causing UTI. IN an intact infant, the proper care is to do nothing. If the infants who had not been circumcised had been left alone, they might have developed even fewer urinary tract infections.

       Dr. Benjamin Spock, in early editions of his influential book on child-rearing, recommended circumcision. He changed his position in the 4th edition and in subsequent editions, and expressed the wish that he had had the foresight to recommend against circumcision in earlier editions.

Circumcision is Not a Universal Practice

       Virtually all European males are intact. Europeans recognize that there are not medical indications for routine neonatal circumcision. The American Academy of Pediatrics has also been saying that for 18 years, and they continue to say it, but they are not saying it loud enough.

       The irony is that this mutilation is perpetuated by a small percentage of the doctors in America, perhaps 5 or 6%. The vast majority of doctors have nothing to do with it, and most do not approve of it. yet those few who continue the outdated practice are giving the entire profession a bad name. Operating on a human being without a medical justification, and without his consent is inconsistent with most other medical care.

The Business of Circumcision

       Circumcision, or foreskin amputation, is big business. Each one costs over $100, divided between the doctor and the hospital. At its peak, there were over one million a year. This added up to well over 100 million dollars every year. Insurers need not pay for this unnecessary surgery, and they can save much needed health dollars at the same time.

Conclusion

       Most parents are not fully informed about circumcision before it is performed on their newborn son. It is truly the removal of an important body organ, and it is very painful to have surgery in this sensitive area without anesthesia. If they really understood this, would they really want to convey to him that this is the way those who love him are going to treat him? Do they really want to permit anyone to inflict excruciating pain in his most sensitive organ? That message can stay with him throughout his life, according to many scientists, and some of the victims.

       Being fully informed about circumcision includes having both parents watch a videotape as it will be performed on their son., There is no other way that they can know what is actually being done. Without his actual witnessing, there can be no informed consent.

      

REFERENCES

  1. Hunter, Richard H. Notes on the Development of the Prepuce, Journal of Anatomy, vol. 70 (1935): pp. 68-75.
  2. Gairdner, Douglas. The Fate of the Foreskin, British Medical Journal. (December 24, 1949): pp. 1433-1437.
  3. Ibid.
  4. Winberg, Jan et al. The Prepuce: A Mistake of Nature? The Lancet, (March 18, 1989): pp. 598-599.

BIOGRAPHY

George Denniston, M.D., M.P.H., specializes in Preventive Medicine and Gynecology and has published extensively in his specialty. He has produced a number of medical training films and documentaries and has served with many medical and professional organizations. Dr. Denniston was formerly Associate Medical Director of Planned Parenthood Federation of America, New York. He is President and Medical Director of Population Dynamics in Seattle, Washington, and Consultant, to the Alaska Women's Health Services. He serves on the Advisory Council of the International Symposia on Circumcision.

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