Table of Contents
| Introduction | ix |
| Chapter 1 | What Is the Foreskin? Anatomical and Physiological Facts That Your Doctor May Not Know | 1 |
| Chapter 2 | The Functions of the Foreskin | 17 |
| Chapter 3 | What Happens to a Baby During a Circumcision? | 31 |
| Chapter 4 | Proven Complications and Risks of Circumcision | 51 |
| Chapter 5 | Disadvantages of Circumcision | 83 |
| Chapter 6 | Circumcision in Religion | 95 |
| Chapter 7 | The History of Circumcision | 118 |
| Chapter 8 | Are There Medical Benefits to Routine Circumcision? | 147 |
| Chapter 9 | Common Nonmedical Excuses for Routine Circumcision | 180 |
| Chapter 10 | Most Common Reasons Given for Postneonatal Circumcision: How to Protect Your Genitally Intact Son from Unnecessary Penile Surgery | 191 |
| Chapter 11 | The Care of Your Son's Intact Penis | 208 |
| Chapter 12 | Care of the Circumcised Penis | 215 |
| Chapter 13 | Afterthoughts | 224 |
| Appendix A | Position Statements on Circumcision of National and International Medical Associations | 228 |
| Appendix B | Resources and Organizations | 231 |
| Appendix C | Recommended Reading | 234 |
| Source Notes | 241 |
| Index | 291 |
Read a Sample Chapter
What Your Doctor May Not Tell You About Circumcision
By Paul M. Fleiss and Frederick M. Hodges Warner Books
Copyright © 2002 Paul M. Fleiss, M.D.
All right reserved. ISBN: 0-446-67880-5
Chapter One
What Is the Foreskin? Anatomical and Physiological Facts That Your Doctor May Not Know
The prepuce is a common anatomical structure of the male and female external genitalia of all human and non-human primates; it has been present in primates for at least 65 million years, and is likely to be over 100 million years old, based on its commonality as an anatomical feature in mammals. Christopher J. Cold, M.D., and John R. Taylor, M.D.
WHAT IS THE FORESKIN?
The foreskin-also known as the prepuce-is the flexible, doublelayered sheath of specialized skin that covers and protects the glans (or head) of the normal penis. The foreskin is a uniquely specialized, sensitive, and functional organ of touch. No other part of the body serves the same purpose.
The foreskin is an integral and important part of the skin system of the penis. It is a complex and sophisticated structure with many interesting and unique properties. No other part of the body's skin covering duplicates the amazing design and functional possibilities of the foreskin. Among the many interesting features of the foreskin is the fact that it is highly elastic, entirely devoid of any subcutaneous fat, and lined with a sheet of smooth muscle.
The foreskin is more than just skin; it is a complex, highly mobile, and beautifully engineered organ composed of an intricate web of blood vessels, muscle, and nerves. In fact, the foreskin contains about 240 feet of nerve fibers and tens of thousands of specialized erotogenic nerve endings of various types, which can feel the slightest pressure, the lightest touch, the smallest motion, the subtlest changes in temperature, and the finest gradations in texture.
Nature has designed the delicate glans (commonly called the head of the penis) to be an internal organ. In the normal, intact penis, the glans is a glistening, rich red or purple color. The foreskin protects the glans and keeps it in excellent condition.
In many ways, the foreskin is just like the eyelid. It covers, cleans, and protects the glans just as the eyelid covers, cleans, and protects the eye. Also, just as the eyelid can open and close to uncover the eye, so the foreskin can open to reveal the delicate glans. The foreskin's inside fold is lined with a smooth red tissue called mucous membrane. This type of tissue is also found lining the lips, the inside of the mouth, and the inner fold of the eyelid. The foreskin's soothing inner fold gently keeps the surface of the glans healthy, clean, shiny, warm, soft, moist, and sensitive.
The akroposthion is the useful name that the ancient Greeks gave to the tubular, tapered "neck" of the foreskin that extends beyond the glans (head). The akroposthion smoothly extends beyond the glans, forming a soft, tapered, tubular sheath. This akroposthion of the foreskin functions as an extension of the urethra and conveys urine from the meatus (the urinary opening in the glans) to the outside world. The akroposthion varies in length between individuals. In childhood, it can represent at least half the length of the penis. Some boys have a foreskin that extends an inch or more beyond the glans. In other males, the akroposthion can be almost nonexistent, in which case the meatus and the surrounding portion of the glans may be exposed. Whatever the case, all lengths are normal.
The foreskin is the largest part of the skin system of the penis. It covers and usually extends far beyond the glans before folding under itself to its circumferential point of attachment just behind the corona (the rim of the glans). The foreskin is, therefore, a double-layered organ. Its true length is twice the length of its external fold and comprises as much as 80 percent or more of the penile skin covering. In children, the foreskin often runs to impressive lengths, frequently representing over three quarters of the length of the penis.
If the average adult foreskin were unfolded and laid flat and unstretched, it would be approximately the size of a 3 x 5 index card. Moderately stretched, it would entirely cover a man's forehead or the back of his hand and fingers. That's a lot of skin!
DOES THE FORESKIN HAVE MUSCLES?
Yes. The foreskin, like the rest of the penile skin system and scrotum, is lined with the dartos muscle sheet. It is also called the peripenic muscle because it wraps around (peri) the penis (-penic). This remarkably powerful muscle is composed of smooth muscle fibers that run parallel to the shaft of the penis. The dartos muscle is involuntary and highly responsive. It contracts and relaxes in response to touch, temperature, and sexual excitement.
The dartos muscle is always in a state of tonus, or partial contraction-a condition of tension or readiness to contract or relax. The contractions of the dartos muscle are slow, sustained, and may produce great force, such as in cold temperatures.
WHAT ARE EVERSION AND REVERSION?
Eversion is the natural mechanical process by which the lips of the foreskin open and allow the foreskin to unroll and slide down the shaft of the penis to reveal the glans. When fully everted, the inner fold of the foreskin that embraces the glans is turned inside-out and moves along the shaft of the penis. Reversion is the reverse process that rolls the foreskin back up the shaft of the penis to cover the glans. Following eversion, the elastic skin system of the penis will usually have a tendency to return to its normal position, re-covering the glans and pursing the lips of the foreskin. Reversion is accomplished through the springlike action of the frenulum.
WHAT IS UNIQUE ABOUT THE PREPUTIAL
At the very end of the foreskin lies the rose-colored preputial orifice, also known as the lips of the foreskin. Here, the muscle fibers form a kind of sphincter that ensures optimum protection of the urinary tract from contaminants of all kinds. This functions similarly to the sphincter that closes and purses the lips of your mouth.
In terms of sensitivity, the lips of the foreskin are probably even more sensitive than the lips of the mouth in their ability to detect subtle differences in temperature, pressure, motion, and touch. The orifice remains closed most of the time, but can open up to allow the passage of urine. Thanks to its highly elastic nature, the preputial sphincter can easily and comfortably dilate over ten times its normal diameter to allow the glans to protrude.
WHAT IS SPECIAL ABOUT THE INNER SURFACE OF THE FORESKIN?
Like the undersurface of the eyelids or the inside of the cheek, the undersurface of the foreskin is lined with a rich red-colored mucous membrane. It is divided into two distinct zones: the smooth mucosa and the ridged mucosa. The smooth mucosa lies against the glans penis. Here, researchers have discovered apocrine and ectopic sebaceous glands that secrete emollients, lubricants, and protective antibodies. Similar glands are found in the eyelids and mouth.
WHAT DOES THE RIDGED MUCOSA DO?
Adjacent to the smooth mucosa and just behind the lips of the foreskin is the ridged mucosa. This exquisitely sensitive structure consists of tightly pleated concentric bands, like 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. The ridged mucosa is a highly vascular zone of specialized sensory tissue containing a dense concentration of specialized erotogenic nerve receptors. Eversion and reversion of the foreskin during erection and sexual play cause the pleats of the ridged mucosa to expand and contract like the bellows of an accordion. This movement allows every surface of the pleats to come in contact with the rim of the glans. The unfolding and refolding of the ridged mucosa over the glans allows all the erotogenic nerve endings to be stimulated, increasing sexual pleasure. If the foreskin is fully everted, the ridged mucosa will be repositioned around the shaft of the penis.
WHAT IS THE SMOOTH MUCOSA?
The last segment of the internal foreskin is the smooth mucosa, which extends from the last ridge of the ridged mucosa to the point of attachment at the coronal sulcus. The surface of this segment is composed of stratified squamous epithelial mucous membrane.
WHAT IS THE FRENULUM?
On the underside of the glans, the foreskin's point of attachment to the body of the penis is the muscular, bandlike ligament called the frenulum. If you turn your lower lip down, or your upper lip up, you will see a similar ligament that serves a very similar function in holding the lips in place. The tongue also has a frenulum that holds it in place. The frenulum functions as a spring, holding the foreskin in place over the glans and also drawing it back over the glans (reversion) after the foreskin has been retracted (eversion).
AT WHAT AGE WILL THE FORESKIN
At birth, the foreskin is usually attached to the glans (head) of the penis, very much as a fingernail is attached to a finger. By the end of puberty, the penis will usually have completed its development, and the foreskin will have separated from the glans. Separation of the glans and foreskin occurs as a result of hormones secreted during childhood and puberty. Erections, which naturally induce the foreskin to retract, also stimulate the separation process. This separation occurs in its own time. It is very important to realize that there is no set age by which the foreskin and glans must be separated. Even if the glans and foreskin separate naturally in infancy, the lips of the foreskin can normally dilate only enough to allow the passage of urine. This ideal feature protects your young son's glans from premature exposure to the external environment.
The penis develops naturally throughout childhood. Eventually, the child will, on his own, make the wondrous discovery that his foreskin will retract. There is no reason for parents, physicians, or other caregivers to manipulate a child's penis. The only person to retract a child's foreskin should be the child himself, and only when he has discovered that his foreskin is ready to retract.
Parents should protect their child from doctors who try to retract his foreskin. Many doctors never learned about the normal development and care of the penis and are unaware that the foreskin should never be retracted by anyone, except its owner, and only when the penis has matured enough to make retraction free and easy.
WHY ISN'T THE FORESKIN USUALLY RETRACTABLE
There is no need for the foreskin to be retractable until puberty. Only then are humans biologically programmed to become sexually mature. In babies and young children, the natural attachment of the foreskin to the glans protects the immature glans from injury and dirt. The firmly attached foreskin provides a natural protective barrier for the urinary tract. This is especially important in infancy and during the diaper-wearing years. Of equal importance, the attachment of the foreskin to the glans protects and preserves the head of the penis, allowing it to complete its development.
IS IT NECESSARY FOR THE FORESKIN TO BE
No. Many adults enjoy the comfort and security of a glans that is covered most or all of the time-even during erection. At this stage of life, the foreskin almost always has fully separated from the head. Full retraction is sometimes avoided if the lips of the foreskin (the preputial orifice) resist stretching wide enough to permit the passage of the glans. There is nothing wrong with this, even though many old-fashioned textbooks and many uninformed doctors (most of whom are circumcised) think that this is a problem called "phimosis."
Contrary to medical myth, a narrow preputial orifice does not make hygiene difficult. On the contrary: Important studies have found that the penis with a narrow foreskin opening is perfectly clean. Urination through the foreskin actually helps keep the penis clean and fresh. It is a beautifully designed system that functions with perfect efficiency.
EMOLLIENTS IN THE FORESKIN
All skin surfaces of the body require the constant moisturizing and soothing action of sebum-natural skin oil. Without it, the skin would dry out, crack, and bleed. To prevent this from occurring, the skin of the body is richly supplied with sebaceous glands. The natural secretion of skin oil gives the skin a healthy luster and enables it to do its job protecting the internal structures of the body from the external environment. Like skin, mucous membranes also require constant moistening. The mucous membranes of the eyes, for instance, are constantly bathed in moistening tears and other lubricating secretions from sebaceous glands in the inner eyelid. Similarly, the surfaces of the penis also require lubrication and moistening.
PREPUTIAL SEBUM (SMEGMA) AND ITS IMPORTANT ANTIBACTERIAL PROPERTIES
Preputial sebum, or smegma, is the creamy white emollient that can sometimes be found coating the inner lining of the foreskin. It is a combination of secretions from many glands around the penis and urethra.
Smegma is probably the most misunderstood, most unjustifiably maligned substance in nature. Smegma is clean rather than dirty. It is beneficial and necessary. It moisturizes the glans and keeps it smooth, soft, and supple. Its antibacterial and antiviral properties keep the penis clean and healthy. All normal male and female mammals produce smegma. Dr. Thomas J. Ritter underscored its importance when he commented, "The vertebrate animal kingdom would be depleted without smegma."
Children produce very little smegma. During adolescence, the production of smegma markedly increases as the glands of the penis develop, perhaps in response to elevated testosterone levels. In adulthood, much less smegma is produced.
Continues...
Excerpted from What Your Doctor May Not Tell You About Circumcision by Paul M. Fleiss and Frederick M. Hodges Copyright © 2002 by Paul M. Fleiss, M.D.. Excerpted by permission.
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